The Joint Commission Study

Executive Summary

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The Joint Commission is scheduled to visit Nightingale Community Hospital for its triennial accreditation survey within the next 13 months. The purpose of this document is to provide senior leadership with an outline of the hospital’s current compliance status in the Priority Focus Area of Communication. Recommendations for corrective action are included in this document which are designed to bring the organization into full compliance in the areas where deficits have been identified. The Priority Focus Area of Communication includes 3 Joint Commission (JC) standards relative to Universal Protocol. These 3 standards, which are components of the National Patient Safety Goals, are aimed at ensuring the correct procedure is performed on the correct patient at the correct site. UP.01.01.01 requires the organization to conduct a pre-procedure verification process prior to the start of any procedure. The hospital meets this standard by following its policy titled “Site Identification and Verification (Universal Protocol)” which describes the process that is used prior to the start of any operative or invasive procedure. The hospital’s use of the “Pre-Procedure Hand-Off” checklist provides the documentation required to demonstrate compliance with the standard. Because of the criticality of this standard, I recommend a focused medical record review to measure compliance with the use of the pre-procedure checklist.

If the audit reveals the checklist is completed consistently, full compliance with the standard will be verified and no further action will be required. UP.01.02.01 requires the organization to mark the procedure site before the procedure is performed. The Site Identification and Verification policy describes the process for marking the operative site however the policy as written does not meet the full intent of the standard. The policy states the patient will identify and mark the operative site. Element of Performance 3 of the standard requires the procedure site to be marked by the licensed independent practitioner who is accountable for the procedure and will be present during the procedure. EP 5 requires a written process for patients who refuse site marking or when it is impossible or impractical to mark the site. This written process is absent in the hospital’s policy. Nightingale’s policy and process must be revised immediately to reflect all the required elements of the standard. Hospital physicians and staff must be educated on the necessary changes and the revised process must be put into action. Once these changes have occurred, I recommend a focused audit to ensure full compliance with the revised policy/process. UP.01.03.01 requires a time-out before the start of the procedure.

The Site Identification and Verification policy describes the time-out process however the policy falls short of fully meeting the intent of this standard. EP 2 describes which team members must participate in the timeout, EP 3 requires a time-out before each procedure when two or more procedures are being performed, and EP 5 requires documentation of the time-out. These 3 elements are missing from the hospital policy/process and therefore revisions to the process/policy are necessary to include these 3 elements. Nightingale’s Safety Report reveals increasing compliance (nearing 100%) with the time-out process, however as mentioned above, EP 5 requires documentation of the process. In addition to the policy revision, I recommend the development of a unique form which will be used to document completion of the time-out and the names of the participants in the time-out. Once these changes have been implemented, I recommend additional auditing to ensure full compliance with documentation of the time-out process. The Joint Commission reports more than 900 Sentinel Events related to wrong site surgery occurred between 1995-2010 (The Joint Commission, 2010) Their research found that 70% of the time, the root cause of wrong site surgery was communication failure (Mulloy and Hughes 2008).

When it occurs, wrong site surgery can be devastating for patients and it can leave a lasting, negative impact on the surgical team. Surgeons are at risk of losing their license and hospitals risk losing reimbursement. When these events occur the risk of litigation exists as well. Wrong-site, wrong-procedure and wrong-person surgery can be prevented! The Priority Focus Area of Communication as it relates to Universal Protocol is essential to Nightingale Community Hospital for preventing wrong site surgery and promoting a safe environment within our hospital. The hospital’s Site Identification and Verification policy was developed with good intentions to meet that goal. The 3 key elements to preventing wrong site surgery; 1) pre-op verification process; 2) marking the operative site; and 3) taking a time out, are all present in the policy however there are additional elements required by the Joint Commission that are missing from the policy and leave the organization and patients at risk.

In order to live up to our core value of safety and to ensure full accreditation with the Joint Commission, it is important for the organization to fully meet all the elements of performance. The changes outlined within this document will strengthen the policies and procedures that are intended to prevent harm to patients and will bring the organization into full compliance with the JC standards. These actions will ultimately ensure that a truly safe environment exists within the walls of Nightingale Community Hospital for the benefit of its patients, associates and the community.

The Joint Commission. (2010, 11 23). Sentinel event statistics as of September 30, 2010. Retrieved from Mulloy, D. F., & Hughes, R. G. (2008). Patient safety & quality: an evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from

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